[The specific features of imported Plasmodium vivax malaria, Chesson strain type]

The details of imported case of Chesson strain of P. vivax malaria to Russian Federation (Moscow) from border areas between Myanmar and Thailand is given. It might further confirm the expansion of this strain from its original place in the Western Pacific towards other territories in the World, described in various publications.

Malaria microscopy performance in self-presenting febrile patients at four health facilities in Fentale district of East Shewa, Ethiopia

BACKGROUND

Correct and reliable microscopic examination results are vital in appropriate treatment of malaria in endemic areas, mainly where Plasmodiumn falciparum and P. vivax co-exist in Ethiopia. Thus, evaluation of regular malaria microscopy performance is needed.

OBJECTIVES

To evaluate the performance of regular malaria microscopy and antimalarial drug prescription practices for self presenting febrile patients at health facilities located in malaria endemic areas of upper Awash Valley, eastern central Ethiopia.

METHODS

A cross sectional study design was used to recruit 260 febrile patients at four health facilities in Fentale district. All slides collected at health facilities were rechecked in reference laboratories and Kappa score was calculated to see the slide reading agreement.

RESULTS

Malaria parasites from clinical cases were found in 19.6% (51/260) of the total febrile patients of which 82.4% (42/51) were infected with P. vivax and 17.6% (9/51) with P. falciparum. Overall sensitivity, specificity, positive and negative predictive values of regular malaria microscopy readings were 92.2%, 83.7%, 58% and 97.8%, respectively. Artemether-lumefantrine over prescription rates was 50.8% by the regular microscopy and 53.6% by reference microscopy. There was only a moderate agreement between regular malaria microscopy and reference microscopy with the Kappa value of 0.52.

CONCLUSION

The overall reading agreement and agreement on species identification of the regular and reference microscopy were low. There was variability in performance in the different health facilities. Sensitivity, specificity, and positive predictive value of regular malaria microscopy need to be improved for accurate diagnosis and prompt treatment of malaria cases in Fentale district health facilities. There should be rational use of antimalarials especially on slide negative subjects.

[Field application of multiplex PCR to distinguish Plasmodium vivax and Plasmodium falciparum]

OBJECTIVE

To explore the application value of multiplex PCR in the diagnosis of malaria in field.

METHODS

The plasmodium genus-specific primer, Plasmodium vivax, P. falciparum species-specific primers were synthesis based on the specific target segments of small subunit of 18 S rRNA ribosomal. The multiplex PCR system was optimized, and a PCR diagnostic method of malaria was established based on the genomic specific DNA fragment of P. vivax, and P. falciparum was amplified in the same PCR reaction system. The sensitivity, specificity, and the value of field application of the multiplex PCR were investigated.

RESULTS

The sizes of amplification products of multiplex PCR amplifying genomic DNA of P. vivax and P. falciparum were 833 bp and 1 451 bp, respectively, and the amplification did not take place with the samples DNA of P. berghei, P. cynomolgus and healthy human blood. The sensitivities of multiplex PCR to detect P. vivax and P.falciparum were 1.1 x 10(-6) and 5.6 x 10(-7) parasitemia, respectively. Compared with the microscopic examination, the positive rate of multiplex PCR to detect 119 cases of field samples was 54%, missed diagnosis rate was 0.8%, and the misdiagnosis rate was naught, while the positive rate of the microscopic examination was 53%, its misdiagnosis rate and missed diagnosis rate were 1.7% and 3.4%, respectively. The compliance rate between the multiplex PCR and microscopic examination was 94%.

CONCLUSION

The multiplex PCR for detecting malaria is simple, rapid, specific, sensitive, etc., which is suitable for the differential diagnosis of suspected cases, and molecular epidemiology investigation.

Acute pancreatitis in a patient with vivax malaria

CONTEXT

Acute pancreatitis is most commonly linked to gallstone disease or alcohol consumption. Occasionally it can follow infectious disease. Malaria, especially Plasmodium falciparum infection, has been associated with acute pancreatitis.

CASE REPORT

We present the case of a 17-year-old male who presented with a history of fever, abdominal pain and hypotension and revealing acute pancreatitis associated with infection by Plasmodium vivax.

CONCLUSION

Acute pancreatitis can accompany malaria, including Plasmodium vivax.

Clinical and epidemiological profiles of severe malaria in children from Delhi, India

Plasmodium vivax is traditionally known to cause benign tertian malaria, although recent reports suggest that P. vivax can also cause severe life-threatening disease analogous to severe infection due to P. falciparum. There are limited published data on the clinical and epidemiological profiles of children suffering from 'severe malaria' in an urban setting of India. To assess the clinical and epidemiological profiles of children with severe malaria, a prospective study was carried out during June 2008-December 2008 in the Department of Pediatrics, Guru Teg Bahadur Hospital, a tertiary hospital located in East Delhi, India. Data on children aged < or = 12 years, diagnosed with severe malaria, were analyzed for their demographic, clinical and laboratory parameters. All patients were categorized and treated as per the guidelines of the World Health Organization. In total, 1,680 children were screened for malaria at the paediatric outpatient and casualty facilities of the hospital. Thirty-eight children tested positive for malaria on peripheral smear examination (2.26% slide positivity rate). Of these, 27 (71%) were admitted and categorized as severe malaria as per the definition of the WHO while another 11 (29%) received treatment on outpatient basis. Most (24/27; 88.8%) cases of severe malaria (n=27) were infected with P. vivax. Among the cases of severe malaria caused by Plasmodium vivax (n=24), 12 (50%) presented with altered sensorium (cerebral malaria), seven (29.1%) had severe anaemia (haemoglobin <5 g/dL), and 17 (70.8%) had thrombocytopaenia, of which two had spontaneous bleeding (epistaxis). Cases of severe vivax malaria are clinically indistinguishable from severe falciparum malaria. Our study demonstrated that majority (88.8%) of severe malaria cases in children from Delhi and adjoining districts of Uttar Pradesh were due to P. vivax-associated infection. P. vivax should, thus, be regarded as an important causative agent for severe malaria in children.

Comparative study of sensitivity of rapid diagnostic (hexagon) test with calculated malarial parasitic density in peripheral blood

BACKGROUND

Different diagnostic test kits are used for rapid diagnosis of malaria. Most are based on antigen detection (pLDH, Pan Aldolase, HRP-2). In context of Nepal the diagnostic reliability and sensitivity of these tests is unknown. Hexagon Malaria Combi™ is one of the most commonly used test kit in Nepal for rapid diagnosis of malaria. The aim of the present study is to evaluate the sensitivity of the Hexagon malaria Combi test in comparison with parasitic density by microscopy technique.

METHODS

A Cross sectional prospective study was conducted in three districts of Nepal from September to November 2009. Blood samples were collected from the suspected cases of malaria. Thick and thin smear were prepared from all the samples and Giemsa stain was done. Simultaneously RDT (hexagon) for malaria was done. When RDT was found to be positive, blood was serially diluted in 6 tubes as 1:2, 1:4, 1:8, 1:16, 1:32 and 1:64. RDT was done on diluted blood till RDT test gave negative result. Parasitic density was calculated for undiluted and diluted blood samples and sensitivity of RDT in various parasitic densities was calculated.

RESULTS

Hexagon malaria combi test is sensitive (86%) when malarial parasitic density is >500/μl. Sensitivity was found to be directly related to parasitic density. Its sensitivity is very low (2.9%) when parasitic density is less than 500/ μl.

CONCLUSIONS

The sensitivity of rapid diagnostic test (hexagon Combi test detecting malarial pLDH antigen) is high only if the parasitic density is more than 500/μl.

[Malaria in Poland in 2010]

OBJECTIVES

The objective of this study was to describe the epidemiology of imported malaria in Poland in 2010 in comparison to previous years.

METHODS

The study included malaria cases that were collected and registered by the State Sanitary Inspection in 2010 in Poland. Data reported was verified, processed and published by National Institute of Public Health - National Institute of Hygiene. All cases were laboratory confirmed by blood film, polymerase chain reaction or rapid diagnostic tests outlined by the EU case definition. Differences in the distribution of demographic, parasitological and clinical characteristics, and incidence were analyzed.

RESULTS

In 2010, a total of 35 confirmed malaria cases were notified in Poland, 13 more than 2009. All cases were imported, 49% from Africa, including 1 case with relapsing malaria caused by P. vivax and 2 cases of recrudescence falciparum malaria following failure of treatment. The number of cases acquired in Asia (37% of the total), mainly from India and Indonesia, was significantly higher than observed in previous years. Among cases with species-specific diagnosis 19 (63%) were caused by P. falciparum, 9 (30%) by P. vivax, one by P. ovale and one by P. malariae. The median age of all cases was 42 years (range 9 months to 71 years), males comprised 69% of patients, females 31%, three patients were Indian citizens temporarily in Poland. Common reasons for travel to endemic countries were tourism (57%), work-related visits (37%), one person visited family and in one case the reason for travel was unknown. Sixteen travelers took chemoprophylaxis, but only three of them appropriately (adherence to the recommended drug regimen, continuation upon return and use of appropriate medicines). In 2010, there were no deaths due to malaria and clinical course of disease was severe in 7 cases.

CONCLUSIONS

When compared with 2009, there was a marked increase in the number of imported malaria cases in Poland, however the total number of notified cases remained low. Serious malaria (caused by P. falciparum), most frequently due to delayed diagnosis and treatment, is a continual problem. Such cases underline the need for adequate pre-travel information regarding the risk of malaria and preventive measures available.

Molecular screening of Plasmodium infections among migrant workers in Thailand

BACKGROUND & OBJECTIVE

A cross - sectional study was conducted to determine the prevalence of Plasmodium infections among migrant workers in Thailand.

METHODS

A total of 241 migrants at Kanchanaburi, Pathumthani and Nakornpathom provinces of Thailand were recruited in our surveillance. Blood samples were examined for human malaria parasites by using microscopy and semi - nested multiplex PCR (SnM- PCR).

RESULTS

Laboratory diagnosis revealed 6.2% total positive rate. As compared to microscopy (26.7%), SnM- PCR was more sensitive (93.3%) for malaria. Plasmodium falciparum was predominant than P. vivax (53% : 40%, respectively). The majority of positive cases were from Myanmar workers who had low parasitaemia and without symptoms. The highest prevalence (13.7%) was found among migrant workers from Kanchanaburi province in western Thailand.

CONCLUSION

These findings indicate risk of malaria transmission from migrant workers. Malaria surveillance should be included in the health- screening program for migrants in Thailand to manage this health risk.

A study on pulmonary manifestations in patients with malaria from northwestern India (Bikaner)

BACKGROUND & OBJECTIVES

Plasmodium falciparum (Pf) and Plasmodium vivax (Pv) are responsible for most of the global burden of malaria. With changing spectrum of clinical presentation in malaria, pulmonary system involvement has always been under diagnosed. The present study was planned to estimate the pulmonary system involvement in patients with malaria from north- western India (Bikaner). STUDY DESIGN & DESCRIPTION OF THE PATIENTS: Our study was conducted during 2007 to 2009 in 200 cases of severe malaria [Pf , Pv, and mixed (Pf + Pv)] with pulmonary involvement. It included adult patients of both sexes (145 males and 55 females) belonging to all age groups. The diagnosis of Pf and Pv was confirmed by demonstrating asexual form of parasites in peripheral blood smear and OptiMal test.

MAIN OUTCOME MEASURES

Pulmonary involvement was observed in 30% (60/200) patients among which cough in 24% , dyspnea in 12%, acute respiratory distress syndrome (ARDS) in 7% , bronchitis in 3% and pneumonia in 1.5% were the major clinical manifestations of malaria. Metabolic acidosis and low oxygen saturation was observed in 7% patients. Chest X- ray abnormality in 11.5% patients, 7% had bilateral infiltrates, 1.5% had inflammatory patch and 3% had findings suggestive of bronchitis. Spirometry findings showed 17% patients had early small airway obstruction. All the patients with ARDS had poor disease outcome.

RESULTS & CONCLUSION

Our results suggest that pulmonary system involvement was observed in patients infected with Pf and Pv. If these clinical presentations are ignored, it may lead to delay in diagnosis and can alter the outcome and prognosis of the disease. Therefore, early diagnosis of malaria induced ARDS can significantly affect the outcome.

Thrombocytopenia in vivax and falciparum malaria: an observational study of 131 patients in Karnataka, India

BACKGROUND

Thrombocytopenia has been reported in the majority of malaria studies. Some but not all studies suggest the possible role of platelets in the pathology of severe malaria. We assess the association of admission platelet count with malaria complications and mortality in vivax and falciparum malaria.

METHODS

This is a prospective, observational study of patients aged 18 years and above admitted in a tertiary care teaching hospital from August 2004 to July 2006 in Manipal, India. Malaria was diagnosed based on clinical features along with positive Quantitative Buffy Coat method (QBC MP) or thin blood smear examination (Giemsa stain). Platelet counts were measured using Coulter LH 756 Analyser. Thrombocytopenia was defined as a platelet count <150×10(9)/l.

RESULTS

A total of 131 consecutive patients were included. Sixty patients (46%) were infected with Plasmodium vivax and the rest with Plasmodium falciparum. Forty-six (35%) patients had non-severe and 24 (18%) had severe falciparum infection. The prevalence of thrombocytopenia was similar in vivax and falciparum malaria. Patients with severe falciparum malaria had a statistically significant lower platelet count (P = 0·01) compared to non-severe falciparum malaria. Severe malaria patients with renal failure (P = 0·02) or hyperparasitaemia (P = 0·03) had a statistically significant lower mean platelet count compared to non-severe falciparum malaria. Patients with involvement of more than one organ system had a lower mean platelet count compared to those with single organ involvement.

CONCLUSIONS

The incidence of thrombocytopenia was similar in vivax and falciparum malaria. The admission platelet count is significantly lower in patients who have hyperparasitaemia and acute renal failure compared to patients without complications.

Systematic review and meta-analysis: rapid diagnostic tests versus placental histology, microscopy and PCR for malaria in pregnant women

BACKGROUND

During pregnancy, malaria infection with Plasmodium falciparum or Plasmodium vivax is related to adverse maternal health and poor birth outcomes. Diagnosis of malaria, during pregnancy, is complicated by the absence or low parasite densities in peripheral blood. Diagnostic methods, other than microscopy, are needed for detection of placental malaria. Therefore, the diagnostic accuracy of rapid diagnostic tests (RDTs), detecting antigen, and molecular techniques (PCR), detecting DNA, for the diagnosis of Plasmodium infections in pregnancy was systematically reviewed.

METHODS

MEDLINE, EMBASE and Web of Science were searched for studies assessing the diagnostic accuracy of RDTs, PCR, microscopy of peripheral and placental blood and placental histology for the detection of malaria infection (all species) in pregnant women.

RESULTS

The results of 49 studies were analysed in metandi (Stata), of which the majority described P. falciparum infections. Although both placental and peripheral blood microscopy cannot reliably replace histology as a reference standard for placental P. falciparum infection, many studies compared RDTs and PCR to these tests. The proportion of microscopy positives in placental blood (sensitivity) detected by peripheral blood microscopy, RDTs and PCR are respectively 72% [95% CI 62-80], 81% [95% CI 55-93] and 94% [95% CI 86-98]. The proportion of placental blood microscopy negative women that were negative in peripheral blood microscopy, RDTs and PCR (specificity) are 98% [95% CI 95-99], 94% [95% CI 76-99] and 77% [95% CI 71-82]. Based on the current data, it was not possible to determine if the false positives in RDTs and PCR are caused by sequestered parasites in the placenta that are not detected by placental microscopy.

CONCLUSION

The findings suggest that RDTs and PCR may have good performance characteristics to serve as alternatives for the diagnosis of malaria in pregnancy, besides any other limitations and practical considerations concerning the use of these tests. Nevertheless, more studies with placental histology as reference test are urgently required to reliably determine the accuracy of RDTs and PCR for the diagnosis of placental malaria. P. vivax-infections have been neglected in diagnostic test accuracy studies of malaria in pregnancy.

Plasmodium vivax malaria in a Romanian traveller returning from Greece, August 2011

In August 2011, a Plasmodium vivax malaria infection was diagnosed in a Romanian traveller returning from Greece. This case together with several reports over the past decade of autochthonous cases in Greece highlight that malaria should be considered as differential diagnosis in symptomatic travellers returning from this country. Travellers may serve as sentinels of emerging vector-borne diseases.

[Evaluation of the efficiency of rapid tests to detect malaria patients and parasite carriers in Tajikistan]

The sensitivity of a rapid test versus microscopy of blood samples was studied while examining 7983 dwellers from the republic's endemic areas. The results of blood testing in the Pyanj and Shurobod districts showed agreement with those of blood microscopy. However, its sensitivity in two other districts was as high as 1.9%. Only one of 53 positive tests was verified by microscopy examination. The findings suggest that it is impossible to use the examined tests (Access Bio Inc. Care Start Malaria pLDH 2 line test) under the conditions of Tajikistan; all the more they identify malaria without differentiation in its pathogen types.

[Urgent tasks of malaria elimination programs]

The state-of-the-art of malaria elimination programs worldwide and the advances made in the past decade were analyzed and assessed. The factors contributing to or reducing the achievement of the final objective of malaria elimination--to interrupt the local transmission of the infection and to steadily maintain the achieved successes are given. Technical problems are defined at the final stages of a malaria elimination program. The problems include difficulties in identifying patients and asymptomatic parasite carriers due to the low level of malaria transmission and the absence of highly effective methods for detecting malaria parasites with low parasitemia, as well as mixed malaria infections requiring the use of different treatment regimens and antimalarial drugs. Large-scale uncontrolled population migration is noted to be of importance in spreading the infection in a malaria-free area. The solution of urgent tasks is to improve the existing methods and develop new ones for the detection and treatment of the infection and a package of antimalarial measures.

[A history of malaria in modern Korea 1876-1945]

Although it is not certain when malaria began to appear in Korea, malaria is believed to have been an endemic disease from ancient times. It was Dr. H. N. Allen (1858-1932) who made the first description and diagnosis of malaria in terms of Western medicine. In his first year report (1885) of Korean Government Hospital he mentioned malaria as the most prevalent disease. Very effective anti-malarial drug quinine was imported and it made great contribution in treating malaria. After Japan had annexed Korea in 1910, policies for public health system were fundamentally revised. Japan assumed control of Korean medical institutions and built high-quality Western hospitals for the health care of Japanese residents. The infectious diseases which were under special surveillance were cholera, typhoid fever, dysentery, typhus, scarlet fever, smallpox, and paratyphoid fever. Among chronic infectious diseases tuberculosis and leprosy were those under special control. Malaria, however, was not one of these specially controlled infectious diseases although it was widely spread throughout the peninsula. But serious studies on malaria were carried out by Japanese medical scientists. In particular, a Japanese parasitologist Kobayasi Harujiro(1884-1969) carried out extensive studies on human parasites, including malaria, in Korea. According to his study, most of the malaria in Korea turned out to be tertian fever. In spite of its high prevalence, malaria did not draw much attention from the colonial authorities and no serious measure was taken since tertian fever is a mild form of malaria caused by Plasmodium vivax and is not so much fatal as tropical malaria caused by P. falciparum. And tertian malaria was easily controlled by taking quinine. Although the majority of malaria in Korea was tertian fever, other types were not absent. Quartan fever was not rarely reported in 1930s. The attitude of colonial authorities toward malaria in Korea was contrasted with that in Taiwan. After Japan had set out to colonize Taiwan as a result of Sino-Japanese war, malaria in Taiwan was a big obstacle to the colonization process. Therefore, a lot of medical scientists were asked to engage the malaria research in order to handle health problems in colonized countries caused by malaria. Unlike the situation in Taiwan, malaria in Korea did not cause a serious health problem as in Taiwan. However, its risk was not negligible. In 1933 there were almost 130,000 malaria patients in Korea and 1,800 patients among them died of malaria. The Japanese Government General took measures to control malaria especially during the 1930s and the number of patients decreased. However, as Japan engaged in the World War II, the general hygienic state of the society worsened and the number of malarial patients increased. The worsened situation remains the same after Liberation (1945) and during the Korean war (1950-53).

Validity and reliability of RDT for diagnosis of malaria among febrile children in Jimma Town: southwest Ethiopia

BACKGROUND

Malaria shows variations in its epidemiologic pattern in relation to the local situation. Rapid diagnostic tests (RDTs) have the potential to provide an accurate diagnosis and to determine the prevalence of malaria in ureas.

OBJECTIVE

The purpose of the study was to determine the prevalence of malaria and to evaluate the sensitivity and specificity of RDT for diagnosis of malaria.

METHODS

A health facility based cross-sectional study was conducted from September to November 2006 among Jebrile children of less than five years of age as part of interventional study to develop and test home management of malaria in Jimma Town. Both thick and thin blood smear microscopy were done by trained laboratory technicians. An RDT was conducted to evaluate its specificity, senstivity and relaibility using blood smear microscopy as a gold standard. Data were analsysed using SPSS12.0.1 and STATA 9.1.

RESULTS

A total of 929 febrile children were included in the sunrvey. P. falciparum or/and P. vivax combined together were identified using microscopy in 20.34% offebrile children presented to the health care facility. Forty three (4.63%) febrile children were positive for P. falciparum in their thin blood film microscopy. The sensitivity Iand specificity of RDT was 93.02% and 99.44% where as the positive likelihood ratio was 164.84 and positive predictive value was 88.89%.

CONCLUSION

RDT for malaria had high sensitivity and specificity in the group tested. However, the use of RDT in home management of malaria by community workers should be investigated and the validity and reliability of the RDT should he established before recommending using with home management of malaria.

Comparative study of peripheral blood smear and quantitative buffy coat in malaria diagnosis

A rapid test for diagnosis of malaria based on acridine orange staining of centrifuged blood samples in a microhaematocrit tube (QBC) was compared with Leishman stained thin peripheral blood smear in 287 samples. Malaria was diagnosed in 44 patients by Leishman staining technique and in 65 patients by QBC method. The QBC method allowed detection of an additional 21 cases. Thus the prevalence rate of malaria during the study was 22.65%. In 222 Patients who were negative by the QBC technique, the Leishman stained smears were also negative for malarial parasite. Although QBC method was superior to the smear for malarial parasite detection, species identification was difficult by this technique. The QBC method provides a reliable, quick, easily mastered, accurate method for diagnosis of malaria. The QBC system can also be used in the diagnosis of other parasitic diseases from blood (Filariasis). However, Leishman stained thin blood film still appear superior for species identification.

Plasmodium vivax recurrence following falciparum and mixed species malaria: risk factors and effect of antimalarial kinetics

BACKGROUND

Plasmodium vivax malaria commonly follows treatment of falciparum malaria in regions of co-endemicity. This is an important cause of preventable morbidity.

METHODS

We examined the factors contributing to the risk of recurrence of P. vivax infection after treatment of acute falciparum malaria in a series of clinical trials conducted on the Thai-Myanmar border from 1991 through 2005.

RESULTS

Overall, 10,549 patients (4960 children aged <15 years and 5589 adults) were treated for falciparum malaria; of these patients, 9385 (89.0%) had Plasmodium falciparum monoinfection and 1164 (11.0%) had mixed P. falciparum/P. vivax infections according to microscopic examinations performed at screening. The cumulative proportion of patients with P. falciparum infection recurrence by day 63 was 21.5% (95% confidence interval [CI], 20.3%-22.8%), and the cumulative proportion with P. vivax infection recurrence was 31.5% (95% CI, 30.1%-33.0%). Significant risk factors for P. vivax infection recurrence were mixed infection at enrollment, male sex, younger age, lower hematocrit, higher asexual P. falciparum parasite density (P < .001 for all factors), and P. falciparum gametocytemia at enrollment (P = .001). By day 63, the cumulative risk of vivax malaria after P. falciparum monoinfection was 51.1% (95% CI, 46.1%-56.2%) after treatment with rapidly eliminated drugs (t(1/2) <1 day), 35.3% (95% CI, 31.8%-39.0%) after treatment with intermediate half-life drugs (t(1/2) 1-7 days), and 19.6% (95% CI, 18.1%-21.3%) after treatment with slowly eliminated drugs (t(1/2) > 7 days) (P < .001, by test for trend). Artemisinin-based combinations containing mefloquine or piperaquine, compared with the artemether-lumefantrine and artesunate-atovaquone-proguanil combinations, were associated with a 3.6-fold to 4.2-fold lower adjusted hazard ratio for P. vivax infection recurrence within 63 days after pure or mixed P. falciparum infections (P < .001, for comparisons with artesunate-mefloquine).

CONCLUSIONS

On the Thai-Myanmar border, P. vivax is the most common cause of parasitological failure after treatment for falciparum malaria. Slowly eliminated antimalarials reduce the risk of early P. vivax infection recurrence.

Comparison of microscopical examination and semi-nested multiplex polymerase chain reaction in diagnosis of Plasmodium falciparum and P. vivax

We compared light microscopy examination and a semi-nested multiplex PCR (SnM-PCR) assay in endemic areas of the Islamic Republic of Iran. A total of 68 individuals with malaria-positive and suspected malaria symptoms were included in the study. Giemsa-stained thick blood films were examined under a light microscope for malaria parasites in 100 and 200 fields. DNA was extracted from blood samples and SnM-PCR based on the amplification of the small sub-unit ribosomal RNA (ssrRNA) gene sequences was applied. Microscopical examination showed that 48.5% (33.8% P. vivax and 14.7% P.falciparum) and 50% (35.3% P. vivax and 14.7% P. falciparum) of the samples were positive in 100 and 200 fields respectively. SnM-PCR showed the same results as the 200 field microscopy.

Parasitemia characteristics of Plasmodium vivax malaria patients in the Republic of Korea

Parasitemia characteristics of Plasmodium vivax malaria in temperate regions may differ from those in tropical zones. However, most parasitological and clinical features of P. vivax malaria have been investigated in the latter. In this study, we investigated 383 malaria patients to clarify the parasitemia characteristics of a P. vivax strain in the Republic of Korea (ROK). The mean parasitemia (8,396/µL) was less than half of tropical P. vivax malaria, and multiple invasions of erythrocytes were not rare (53.5% of the patients, 2.4% of the total investigated RBCs), but less than the observations in tropical zones. The intervals between the first symptom onset and diagnosis were significantly longer in gametocyte (+) patients than in gametocyte (-) patients. Only half of the total patients had both genders of gametocytes (191 of 353), and the male gametocyte density (169/µL) was lower than that of P. vivax strains of a previous study. Multiple invasions of erythrocytes and gametocytemia were coincident factors of the degree of anemia in P. vivax malaria. The present findings demonstrate the P. vivax strain in ROK reveals relatively low parasitemia and low male to female gametocyte ratio. The low ratio may be related with low transmission efficacy.

[Malaria in Poland in 2009]

In Poland in 2009 were reported 22 malaria cases confirmed according to the EU case definition for the purposes of routine surveillance system. All of them were imported, including 1 case of recrudescence, 86% from Africa. In 18 cases P falciparum etiology was confirmed and in 2--P vivax, in 1--P ovale and 1 P malariae. Most cases occurred in the age group 21-40 years, there were 21 cases in males and 1 in female. Common reasons for travel to endemic countries were work-related visits (14 cases) and tourism (6 cases), one person who visited the family and in one case unknown reason for travel. Three persons used chemoprophylaxis during their travel but only one of them appropriately, relevant information was missing in 5 cases. Clinical course was severe in 7 cases of P falciparum malaria and medium-severe in one case. In 2009, there were no malaria deaths in Poland. Education on the prevention of malaria and pretravel health advising is still greatly needed.

HIV, malaria and pneumonia in a Torres Strait Islander male--a case report

This report presents the case of a middle-aged Torres Strait Islander male with HIV who contracted Plasmodium vivax malaria in Papua New Guinea. His presentation included clinical and radiological features of pneumonia and he required inpatient treatment for 13 days. This study reviews the literature concerning co-infection with HIV and malaria, which is an uncommon combination in Australia, discusses the public health risks posed by patients with malaria in the Torres Strait, given the presence of a known vector, and suggests strategies to reduce the disease burden posed by malaria in this patient and other Torres Strait Islanders travelling to Papua New Guinea under the terms of the Torres Strait Treaty.

Congenital malaria due to chloroquine-resistant Plasmodium vivax: a case report

The clinical manifestation of malaria in neonates and young infants is non-specific and differs from that of adults and older children. So a high index of suspicion is needed to diagnose malaria in early infancy. Chloroquine is the first-line treatment for Plasmodium vivax malaria in most parts of the world. This case report details a case of chloroquine-resistant malaria due to P. vivax by transplacental transmission from mother with mixed infection of P. falciparum and P. vivax in a 26-day-old young infant who presented with moderate grade fever and reviews the literature of malaria in infantile and neonatal age groups. And we concluded that high suspicion of malaria is needed to diagnose congenital malaria. Primigravida women with placental malaria pose high risk for congenital infection in baby and emerging chloroquine-resistant P. vivax in congenital malaria.

[Acute respiratory distress syndrome (ARDS) as a complication of malaria P.vivax]

The authors review a case of an Indian tourist couple both presenting a clinical picture of intermittent fever, thrombocytopenia and relative leukopenia several days after their arrival to israel. The diagnosis of Plasmodium vivax (P.vivax) malaria was established in both patients and antimalarial treatment with chloroquine was initiated. Shortly after initiating the treatment, the husband developed clinical acute respiratory distress syndrome (ARDS). With symptomatic treatment, the patient recovered within few days. The diagnosis of P. vivax was confirmed by PCR, and was shown to be a single infection with no Plasmodium falciparum as co-infection. Although P. vivax is considered as having a benign course, in contrast to P. falciparum infections, in recent years there have been an increased number of reports of complicated P. vivax malaria, mainly ARDS. Physicians should be aware of the possible complicated course of P. vivax malaria.

Malaria in pregnancy: update on emergency management

BACKGROUND

Pregnancy complicates the diagnosis, treatment, and clinical course of malaria. This clinical problem may be encountered in emergency department patients due to international travel.

CASE REPORT

A primigravida woman at 20 weeks gestation presented to the Emergency Department with episodic fever, chills, headache, and nausea after travel to India and Asia. She had not taken malaria prophylaxis. After hospitalization, she developed acute respiratory distress syndrome and required intensive care management. Although she ultimately recovered from severe infection with Plasmodium vivax, she was not able to sustain her pregnancy and suffered a miscarriage.

CONCLUSION

This case illustrates the serious nature of malaria in the pregnant patient. For this high-risk group, there is an increased incidence of severe anemia, as well as acute respiratory distress syndrome and pulmonary edema. A guideline is presented for the initial choice of anti-malarial drug treatment for the pregnant patient.

Plasma superoxide dismutase-1 as a surrogate marker of vivax malaria severity

BACKGROUND

Severe outcomes have been described for both Plasmodium falciparum and P. vivax infections. The identification of sensitive and reliable markers of disease severity is fundamental to improving patient care. An intense pro-inflammatory response with oxidative stress and production of reactive oxygen species is present in malaria. Inflammatory cytokines such as tumor necrosis factor-alpha (TNF-alpha) and antioxidant agents such as superoxide dismutase-1 (SOD-1) are likely candidate biomarkers for disease severity. Here we tested whether plasma levels of SOD-1 could serve as a biomarker of severe vivax malaria.

METHODOLOGY/PRINCIPAL FINDINGS

Plasma samples were obtained from residents of the Brazilian Amazon with a high risk for P. vivax transmission. Malaria diagnosis was made by both microscopy and nested PCR. A total of 219 individuals were enrolled: non-infected volunteers (n = 90) and individuals with vivax malaria: asymptomatic (n = 60), mild (n = 50) and severe infection (n = 19). SOD-1 was directly associated with parasitaemia, plasma creatinine and alanine amino-transaminase levels, while TNF-alpha correlated only with the later enzyme. The predictive power of SOD-1 and TNF-alpha levels was compared. SOD-1 protein levels were more effective at predicting vivax malaria severity than TNF-alpha. For discrimination of mild infection, elevated SOD-1 levels showed greater sensitivity than TNF-alpha (76% vs. 30% respectively; p<0.0001), with higher specificity (100% vs. 97%; p<0.0001). In predicting severe vivax malaria, SOD-1 levels exhibited higher sensitivity than TNF-alpha (80% vs. 56%, respectively; p<0.0001; likelihood ratio: 7.45 vs. 3.14; p<0.0001). Neither SOD-1 nor TNF-alpha could discriminate P. vivax infections from those caused by P. falciparum.

CONCLUSION

SOD-1 is a powerful predictor of disease severity in individuals with different clinical presentations of vivax malaria.

Congenital Plasmodium vivax malaria mimicking neonatal sepsis: a case report

Although malaria in pregnancy can cause very significant neonatal morbidity, congenital malaria is a very rare condition in both endemic and non-endemic areas. A case of congenital malaria by Plasmodium vivax, initially mistaken for neonatal sepsis, is described. The correct diagnosis was accidentally done, as congenital malaria had been missed in the initial differential diagnosis.Vivax malaria is the leading species in congenital infections in Europe. This condition should be included in the differential diagnosis of neonatal sepsis even if the mother has no proven malarial episodes during the gestational period.

Severe Plasmodium vivax malaria exhibits marked inflammatory imbalance

BACKGROUND

Despite clinical descriptions of severe vivax malaria cases having been reported, data regarding immunological and inflammatory patterns are scarce. In this report, the inflammatory and immunological status of both mild and severe vivax malaria cases are compared in order to explore immunopathological events in this disease.

METHODS AND RESULTS

Active and passive malaria case detections were performed during 2007 in Buritis, Rondônia, in the Brazilian Amazon. A total of 219 participants enrolled the study. Study individuals were classified according to the presence of Plasmodium vivax infection within four groups: non-infected (n = 90), asymptomatic (n = 60), mild (n = 50) and severe vivax infection (n = 19). A diagnosis of malaria was made by microscopy and molecular assays. Since at present no clear criteria define severe vivax malaria, this study adapted the consensual criteria from falciparum malaria. Patients with severe P. vivax infection were younger, had lived for shorter time in the endemic area, and recalled having experienced less previous malaria episodes than individuals with no malaria infection and with mild or asymptomatic infection. Strong linear trends were identified regarding increasing plasma levels of C reactive protein (CRP), serum creatinine, bilirubins and the graduation of disease severity. Plasma levels of tumour necrosis factor (TNF), interferon-gamma(IFN-gamma) and also IFN-gamma/interleukin-10 ratios were increased and exhibited a linear trend with gradual augmentation of disease severity. Both laboratory parameters of organ dysfunction and inflammatory cytokines were reduced during anti-parasite therapy in those patients with severe disease.

CONCLUSION

Different clinical presentations of vivax malaria infection present strong association with activation of pro-inflammatory responses and cytokine imbalance. These findings are of utmost importance to improve current knowledge about physiopathological concepts of this serious widespread disease.

Vivax-induced ARDS: report of two cases

Plasmodium vivax is known for its benign nature but now recognition of life threatening complications related to this infection is on rise. We report two cases of Plasmodium vivax malaria complicated by ARDS. Patients were treated with Artesunate, followed by Sulfadoxin Pyerimethamin combination. Rarely, ARDS is a presenting complication or occurs during the course of Plasmodium vivax.

Malarigen malaria Pf/Pv antigen rapid test: a simple and effective tool for diagnosis of malaria in the far-flung hilly areas of Bangladesh

Microscopic visualization of malarial parasites on thick and/or thin film is considered as "Gold Standard" for diagnosis of malaria. But it needs skilled microscopist as well as good laboratory set up, which are scarce in Chittagong Hill Tracts (CHT) in Bangladesh. A study was carried out to evaluate the efficacy of a newly introduced Rapid Diagnostic Test (RDT) device based on immunochromatographic test (ICT) format, for malarial parasite. This study was carried out at Balipara, a remote village 64 km away from Bandarban Hill District headquarters, during January 2007 to September 2007. A total 271 patients who reported to Sickbay of 37 Rifle Battalion, Balipara were tested by MALARIAGEN MALARIA Pf/Pv Antigen Rapid Test kit on the spot. Thick & thin blood films were prepared and stained by laboratory technician at the sick bay, properly labeled, preserved and sent to pathologist working at Armed Forces Medical College, Dhaka Cantonment, Dhaka for microscopy. Three (1.11%) cases were excluded as control band of RDT were negative or test band appeared after long incubation. Six (2.22%) were excluded for poor quality of staining blood film. Among 262 cases malarial parasites were detected in 74(28.24%). Of these 62(83.78%) were Plasmodium falciparum and 12(16.22%) were Plasmodium vivax. Parasite count ranged from 2500/mµL to 527500/mµL with mean 67400/mµL (+/-93400). Among 262 cases, 97(37.02%) were positive for malarial antigen(s) in RDT. Of these 74(76.29%) were P. falciparum and 23(23.71%) were P. vivax. Overall sensitivity and specificity of RDT for detection of malarial antigen(s) irrespective of their species were 95.95% and 86.71% respectively with positive and negative predictive value 73% & 98% respectively. Relative to microscopy, the device has shown sensitivity 94.6% and specificity 88.52% for detection of P. falciparum with positive and negative predictive value 72% and 98% respectively. The device sensitivity and specificity for detection of P. vivax were 100% and 93.1% with respective positive and negative predictive value 47% and 100%. Malariagen Malaria Pf/Pv Antigen Rapid Test (RDT) performs as a better sensor and discriminator of malarial parasites and their species and appears to be an acceptable tool for diagnosis of malaria in symptomatic patient.

Role of immunochromatographic test for rapid diagnosis of malaria

The study was conducted to compare among the different diagnostic procedures for malaria in the department of Microbiology, Mymensingh Medical College, Mymensingh during the period from July 2005 to June 2006. In this study a total of 98 malaria patients were included as cases. Another 30 age and sex matched healthy people were included as controls. Blood sample from each of the case and control was collected and examined for malarial parasite by microscopic examination of peripheral blood film. Subsequently antigen and antibody were detected by immuno-chromatographic test (ICT). Out of 98 clinically suspected cases 59(60.20%) were positive for malarial parasite by microscopic examination of peripheral blood film, 57(58.16%) were positive by ICT for antigen and 58(59.19%) were positive by ICT for antibody. Sensitivity and specificity of ICT for antigen were 93.22% and 94.87% respectively. For antibody, sensitivity and specificity were 89.83% and 87.17% respectively. From this study, sensitivity and specificity of ICT for malaria was found quite satisfactory, so it is suggested that ICT for malaria could be an alternative to peripheral blood film for the diagnosis of malaria where parasite could not be detected in peripheral blood film.

[Malaria: an evaluation of 40 cases]

In this study, the epidemiological, clinical, laboratory and therapeutic features of forty adult malaria patients referred our clinic between February 1996-September 2009, were assessed retrospectively. Diagnosis was established by Giemsa-stained thick and/or thin blood smears in all cases. Thirty-four patients were male and 6 patients were female and mean age was 31.1 years. All patients had a history of travel to endemic areas (24 cases to Africa, Afghanistan, Azerbaijan, Arabian Peninsula, 16 cases to Southestern Anatolia Region), and none of them had chemoprophylaxis. Plasmodium vivax was detected in 20 patients, and P.falciparum in 18 and mixed (P. vivax and P. falciparum) in two. Parasitemia ranged from 0.5%- 25%. Fever (100%), periodic fever (62.5%), splenomegaly (72.5%), hepatomegaly (45.0%), anemia (67.5%), leukopenia (32.5%), thrombocytopenia (75.0%), a rise in erytrocyte sedimentation rate (65.0%), abnormalities in hepatic enzymes (62.5%), hyponatremia (32.5%), hypoglisemia (25%) and an elevated serum creatinine level (27.5%) were determined in the patients. Two patients with P. falciparum developed acute renal failure and cerebral involvement died soon after admission. Acute renal failure, acute respiratory distress syndrome, cerebral involvement and dissemine intravasculer coagulation were observed in one patient with falciparum malaria who recovered completely. In conclusion, every febril patients with a history of travel to the endemic regions should raise the suspicion of malaria. Effective pre-exposure chemoprophylaxis and personal protection measures should be provided to travellers visiting endemic regions.

[Field evaluation of gold-immunochromatographic assay for diagnosis of vivax malaria]

OBJECTIVE

To evaluate a gold-immunochromatographic assay (GICA) for malaria diagnosis in an endemic area of vivax malaria.

METHODS

Blood samples were collected from febrile patients in 5 township-hospitals of Mengcheng County, Anhui Province, between September and October 2008. The samples were examined by GICA and microscopy under double blind condition and the results were compared.

RESULTS

Among 292 blood samples, 181 were found P. vivax-positive by microscopy, and 163 were positive by GICA. Altogether, the coincidence of the two methods stood for 92.8% (271/292), including 108 negatives and 163 positives. 21 samples with discrepancy covered 18 microscopy positive but GICA negative, 3 microscopy negative but GICA positive. The GICA positive rate in patients with a parasitaemia of > 1,000 parasites/microl, 100-1,000 parasites/microl, and < 100 parasites/microl was 93.5% (115/123), 86.0% (43/50), and 62.5% (5/8), respectively.

CONCLUSION

GICA is a useful diagnosis method for endemic area of vivax malaria.

[The epidemiological and clinical characteristics of malaria under the present conditions of Tajikistan]

The highest malaria morbidity rates have been observed in the Tajikistan's Khatlon Region that is contiguous with Afghanistan. This area is notorious for its high malariogenicity ("susceptibility" according to the WHO terminology), caused by natural climatic factors, as well as a significant vulnerability associated with socioeconomic conditions (intensive migration of populations among which there are many infected subjects). In children, tropical malaria is generally characterized by an acute onset, abnormal fever, and its polymorphism of clinical manifestations that are exemplified by the lack of typical malaria paroxysms, as well as a gradual progression of parasitemia during the first malaria attacks. Recurrences are induced by ineffective treatment and chloroquine resistance in the tropical malaria pathogen. The reduction in malaria morbidity has resulted from a package of large-scale malaria-controlling measures implemented with the support of the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

Evaluation of the performance of CareStart Malaria Pf/Pv Combo and Paracheck Pf tests for the diagnosis of malaria in Wondo Genet, southern Ethiopia

OBJECTIVE

To evaluate the diagnostic performance of CareStart Malaria Pf/Pv Combo test relative to microscopy for the diagnosis of falciparum and vivax malaria in Ethiopia.

METHODS

668 febrile patients visiting two health centers in Wondo Genet, southern Ethiopia, involved in this study in 2008. Giemsa-stained thin and thick blood smears were prepared and microscopically examined under a 100x oil immersion microscope objective for Plasmodium species identification and determination of parasitaemia, respectively. CareStart Malaria Pf/Pv Combo test and Paracheck Pf test were performed as per the manufacturers' instruction.

FINDINGS

The diagnostic validity of CareStart Malaria Pf/Pv Combo test for the diagnosis of Plasmodium falciparum were very good with sensitivity of 99.4%, specificity of 98%, positive predictive value of 94.4% and negative predictive value of 99.8%. Sensitivity, specificity, positive predictive value and negative predictive value of the test for the diagnosis of P. vivax were 99.4%, 98.2%, 94.5% and 99.8%, respectively. The diagnostic performance of CareStart Malaria Pf/Pv Combo test is comparable to that of Paracheck Pf test for the diagnosis of P. falciparum (sensitivity 99.4%, specificity 98.2%).

CONCLUSION

Although CareStart Malaria Pf/Pv Combo test and Paracheck Pf test have comparable diagnostic performance for the diagnosis of P. falciparum, CareStart Malaria Pf/Pv Combo test has the added advantage of diagnosing P. vivax. Hence, it is preferable to use CareStart Malaria Pf/Pv Combo test for the diagnosis of malaria in areas where microscopy is not accessible and where malaria due to P. falciparum and P. vivax are co-endemic as in Ethiopia.

How benign is benign tertian malaria?

OBJECTIVE

This retrospective study was conducted to determine the incidence of various complications of Plasmodium vivax malaria based on review of case records.

METHODS

The case records of all confirmed cases of malaria over the period of one year (September 2005-August 2006) were studied. Complete blood count, peripheral blood findings, liver and kidney functions were reviewed. The results of rapid diagnostic test for malaria (OptiMAL test, Diamed AG, Switzerland) were correlated with the peripheral blood smear findings in the patients in whom it was requested. All abnormal results like a positive direct Coomb's test were noted. Findings were clinically correlated.

RESULTS

There were 265 confirmed cases by peripheral blood examination. Of these 221 were due to Plasmodium vivax and 41 due to P. falciparum. Two cases had mixed infection and in one case the species could not be identified as it showed only malarial pigment. The peak incidence of malaria was seen in September 2005 and August 2006. The complications in P. vivax were thrombocytopenia, biochemical evidence of hepatic dysfunction, renal damage, positive DCT and death due to ARDS. Thrombocytopenia was seen in 213 patients with counts < 20 x 103/microl in 13 patients. Nine (4%) patients had serum bilirubin >3 mg/dl with normal liver enzymes. Liver enzymes were elevated in 60 patients with seven patients showing liver enzymes level, three times the normal. Renal dysfunction was seen in 17 patients with serum creatinine ranging from 1.3-10.65 mg/dl. One patient went into acute renal failure following quinine therapy and showed red cell fragments in the peripheral blood. In two children DCT was positive with the peripheral smear showing RBC agglutinates around the parasitised RBC. There were three maternal deaths at about 32 weeks gestation due to ARDS. The peripheral blood smear in these patients showed WBC agglutinates.

CONCLUSION

This paper is presented to highlight that P. vivax malaria though considered to be a benign entity can also have a severe and complicated course which is usually associated with P. falciparum malaria.